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STATE OF SOUTH DAKOTA COUNTY OF ______________
DOMESTIC

) ) )
STALKING PERMANENT

IN CIRCUIT COURT _________ JUDICIAL CIRCUIT

EX PARTE TEMPORARY

ORDER FOR PROTECTION
TPO NO. _____________________

MODIFICATION

PETITIONER
First Middle Last

PETITIONER IDENTIFIERS:
Date of Birth of Petitioner

By (name and DOB):__________________________ _____________________________________________ On behalf of a minor child by parent/guardian.

Other Protected Persons (name and DOB):______ _____________________________________________

__________________________________________
(See also 1B Additional Orders.)

V. RESPONDENT
First Middle Last

SEX EYES

RESPONDENT IDENTIFIERS: RACE HEIGHT WEIGHT HAIR DATE OF BIRTH STATE EXPDATE

Relationship to Petitioner: _____________________________________________ _____________________________________________ Respondent's Address:
__________________________________________________ __________________________________________________ __________________________________________________

DRIVERS LICENSE #

CAUTION:

Weapon Involved

Distinguishing Features: _____________________________________________ _____________________________________________

That it has jurisdiction over the parties and subject matter, and the Respondent has been provided with reasonable notice and opportunity to be heard, and that in the case of an ex parte order, the Respondent will be provided with reasonable notice and opportunity to be heard sufficient to protect the Respondent's due process rights. That the Respondent is restrained from acts of abuse and physical harm, making threats of abuse, stalking or harassment. That the Respondent is restrained from contact with the Petitioner by any direct or indirect means except as authorized in this order. Additional findings and orders are on the following pages. This order shall be effective through Month/Day Year Month/Day Year or if a permanent order is issued, until that order is served. Only this Court can change this order. VIOLATION OF THIS PROTECTION ORDER IS A CRIMINAL OFFENSE.
WARNING TO RESPONDENT: This order shall be enforced, even without registration, by courts of any state, the District of Columbia, any U.S. Territory, and may be enforced by Tribal Lands (18 U.S.C.§2265). Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. §2262). Form UJS-121I (Stalking Modification of Permanent Order) Rev. 05/08

THE COURT FINDS:

THE COURT ORDERS:

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ADDITIONAL FINDINGS:

This matter came before this Court on this day and the following parties appeared personally: Petitioner Petitioner's Attorney ______________________ Other ____________________ Respondent Respondent's Attorney ___________________ Other ____________________ 1) This Court FINDS that, without admitting to the allegations in the Petition, the Respondent waives further hearing, findings of fact, and conclusions of law, and stipulates to the entry of an Order of Protection on the terms specified below. 2) Having considered the evidence presented and any affidavits and pleadings on file, this Court FINDS: 1. That jurisdiction and venue are properly before this Court; and 2. By a preponderance of the evidence that: a) "stalking" as defined by SDCL 22-19A-1 has taken place; b) that the Petitioner has suffered physical injury resulting from an assault or a crime of violence, as defined by SDCL 22-1-2(9); THEREFORE, THIS COURT ORDERS THAT: 1. The Respondent is restrained from: a) following or harassing the Petitioner, or making any credible threat with the intent to place the Petitioner in reasonable fear of death or great bodily injury, SDCL 22-19A-1; b) harassing the Petitioner by means of any verbal, electronic, digital media, mechanical, telegraphic, or written communication, SDCL 22-19A-1; c) causing any injury as a result of an assault or crime of violence, SDCL 22-1-2-(9). 1) That the Respondent shall not come within a distance of ___________ from the following persons and places: A. The Petitioner personally B. The following minor children named as other protected persons: Name Date of birth Relationship ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ C. The Petitioner's residence (street/apt)_____________________________________________ (city)_______________________________, (state) _______ (zip) _________-_______ D. The Petitioner's place of employment (street)_______________________________________ (city)_______________________________, (state) _______ (zip) __________- _______ E. Other places (street/apt) (city) , (state)_______ (zip) (street/apt) (city) , (state)_______ (zip) (street/apt) (city) , (state)_______ (zip) This distance restriction applies unless otherwise specified in this order. 2) Phone calls, emails, third party contact, and correspondence, direct or indirect, are not permitted, to a protected person, except as follows: __________________________________________________________________________________________ __________________________________________________________________________________________
ADDITIONAL ORDERS:

Form UJS-121I (Stalking Modification of Permanent Order) Rev. 05/08

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3) Respondent is ordered to immediately turn over all weapons and ammunition to local sheriff. 4) Other relief as follows:______________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ AND IT IS FURTHER ORDERED THAT: the Petitioner shall, immediately upon the granting of this Order, deliver two copies of this Order to the sheriff of this county. One copy shall be personally served by the sheriff upon the Respondent, unless personal service has been acknowledged below. DATED / / . Service of this order is authorized on any day including Sunday.

Judge Attest: By: , Clerk of Courts , Deputy NOTICE OF ENTRY OF ORDER AND ACKNOWLEDGMENT OF PERSONAL SERVICE I acknowledge receipt of a copy of this Order of Protection. _______________________________________ Petitioner ___________________________________________ Respondent

UNDER A PERMANENT PROTECTION ORDER: You may be subject to the following federal laws: (1) Effective immediately, you may not possess, carry, ship or transport any firearm or ammunition that has been transported in interstate or foreign commerce while this Protection Order is in effect. Title 18 United States Code Section 922(g)(8). (2) If you violate this Protection Order and are convicted of an offense of domestic violence, you may be forbidden for life from possessing, carrying, shipping or transporting, any firearm or ammunition that has been transported in interstate or foreign commerce. Title 18 United States Code Section 922(g)(9). Violation of these federal laws carries a maximum penalty of ten years in prison, a $250,000 fine, or both.

Form UJS-121I (Stalking Modification of Permanent Order) Rev. 05/08

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